Introduction
What is new?
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The accurate diagnosis of acute appendicitis in children is important to avoid severe outcomes and minimize unnecessary investigations and surgery.
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A high quality and high-performing clinical prediction rule (CPR) could improve the diagnostic accuracy of clinical findings in children with suspected appendicitis.
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Of the six unique CPRs for children with suspected appendicitis, the Pediatric Appendicitis Score and Alvarado scores were the most well validated but neither met the current performance benchmarks. A high quality, well validated, and consistently high-performing CPR was not identified.
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Further research is needed before a CPR for children with suspected appendicitis can be used in routine practice.
Acute appendicitis is the most common reason for abdominal surgery in children, with between 60,000 and 80,000 cases diagnosed annually in North America [1], [2]. The lifetime risk for acute appendicitis ranges from 7% to 9% [3], with a peak incidence of 86 of 100,000/year in the second decade of life [4]. Morbidity in children is high, with an overall frequency of appendix perforation of 12.5–30% [5], [6], [7]. Despite its high incidence and potentially serious consequences, the diagnosis of appendicitis in children remains challenging, in which clinical signs and symptoms can be nonspecific and unreliable and there may be limited availability or concern for using costly and potentially harmful diagnostic tests such as computerized tomography.
Classical clinical signs and symptoms of appendicitis [8] are often lacking on the initial presentation of children with acute abdominal pain. Furthermore, young children often have difficulty in describing their pain, and many nonsurgical conditions such as gastroenteritis and mesenteric adenitis may mimic appendicitis. Additionally, one-third of the children with acute appendicitis present with atypical findings, such as irritability, periumbilical pain, and diarrhea [9]. To overcome the diagnostic uncertainly laboratory evaluation, ultrasonography and computed tomography (CT) are often performed in the emergency department (ED) in children who present with acute abdominal pain. However, such diagnostic evaluation is time consuming, resource intensive, and potentially harmful and may not be needed to routinely rule in or rule out appendicitis. A rapid, safe, and accurate method for diagnosing acute appendicitis in children is urgently needed.
Clinical prediction rules (CPRs) are potentially powerful evidence-based tools for reducing uncertainty and improving accuracy in medical decision making by standardizing the collection and interpretation of clinical data [10]. They also may minimize potentially harmful diagnostic tests such as ionizing radiation from CT, allergic reaction to contrast dye, and complications from diagnostic laparotomy. They have been defined as clinical decision-making tools that quantify the relative importance of three or more variables from history, physical examination, or simple tests to provide the probability of an outcome or suggest a single diagnostic or therapeutic course of action for an individual patient [10], [11], [12].
This study aims to systematically identify CPRs for children with acute abdominal pain and compare their methodological quality and performance for diagnosing acute appendicitis using a recently developed framework to evaluate CPRs for children [13].